PAIR for Hydatid

AJR:172, January 1999 91

PercutaneousTreatment of HydatidCysts of the Liver: Long-Term Results

Bahri Ust#{252}ns#{246}z1Okan Akhan2

MehmetAli KamiIo�lu1Ibrahim SomunCu1Mehmet �ahin U�ureI1Saadettin #{231}etiner3

OBJECTIVE. The purpose of the study was to present the long-term results of percutane-

ous treatment of liver hydatid cysts.

SUBJECTS AND METHODS. Seventy-two patients (44 male and 28 female, ranging

in age between 10 and 69 years; mean age, 35 years) with 106 liver hydatid cysts underwent

percutaneous treatment with albendazole prophylaxis. Puncture, aspiration. injection. and

reaspiration (PAIR) were used for hydatid cysts smaller than 6 cm (n = 66). Larger cysts (ii =

40) were treated by catheterization. Hypertonic saline solution and absolute alcohol were

used as the cytotoxic and sclerosing agents. Sonographic guidance with or without fluoros-

copy was used in all patients. Follow-up was mainly by sonography every third month of the

first year, every sixth month of the second year. and once a year thereafter. The mean follow-

up time was 37 months.

RESULTS. The mean reduction in volume at the time ofthe first follow-up was 87.0% and

73.5% in catheterization and PAIR patients. respectively. The immediate sonographic changes

after treatment were detachment of the endocyst and disappearance of the regular endocyst,

with a reduction in the fluid component. The solid appearance of the cyst remnant indicated

complete cure as the cyst wall became irregular and thicker. The average time for develop-

ment ofa solid appearance was 19 months in PAIR patients and 26 months in catheterization

patients. Seventy of 72 patients were cured, whereas two recurrences (2.8C/e) were observed.

No mortality, abdominal dissemination, or tract seeding occurred. Minor complications were

urticaria and fever in eight patients ( 1 1 . I %). Major complications were infection of the cyst

cavity in two patients (2.8%) and development ofbiliary tistula in four patients (5.6%). Mean

hospitalization times were I 7 days for complicated cases and I day for uncomplicated cases.

CONCLUSION. The long-term results of percutaneous liver hydatid cyst treatment ac-

cord with short-term results, indicating that the procedure is efficient and safe and offers com-

plete cure in selected patients with a short hospitalization.

Received February 12, 1998;accepted after revisionJune 29, 1998.

1 Department of Radiology, GUlhane Military Medical

Academy, 06018 Etlik, Ankara 06100, Turkey. Address

correspondence to B. UstUnsdz.

2DepartmentofRadiology, Hacettepe University, Faculty of

Medicine, Sihhiye, Ankara 06100, Turkey.

3Department of Surgery, GUlhane Military Medical

Academy, 06018 Etlik, Ankara 06100, Turkey.

AJR 1999;172:91-96

0361 -803X/99/1721--91

© American Roentgen Ray Society

H ydatid disease caused by Eehino-

(‘Ot’(’ttS granulosus is endemic and

a common health problem in Med-

iterranean countries, the Middle East. South

America. New Zealand, and Australia I I 1. Thedisease may be asymptomatic, or. rarely. pa-

tients may clinically present with life-threaten-

ing anaphylactic shock from cyst rupture 121.Surgical treatment of hydatid disease is tradi-

tional and carries a higher risk of complica-

tions, death. and lengthy hospitalization than

does nonsurgical treatment 13-51. Nonsurgical

treatment such as percutaneous. endoscopic.

and medical procedures and combinations

such as percutaneous plus medical or percuta-

neous plus endoscopic procedures have been

novel for the last two decades [6-9]. Large

studies with long-term results are lacking.

Among nonsurgical treatments. medical ther-

apy with benzimidazole compounds (albenda-

zole or mebendazole) is not usually curative

[8, 10]. Endoscopic treatment has limited mdi-cations, with a role mostly in biliary hydatid

cysts [9. 1 1 1. Percutaneous treatment of hy-

datid cysts has been gaining acceptance be-

cause of its positive short-term results since it

was first introduced in I 985 by Mueller et al.

I I 2]. We present our long-term results from

percutaneous treatment.

Subjects and Methods

From February 1992 to February 1997. 72 pa-tients (44 male and 28 female: age range, 10-69years: mean age. 35 years) with 106 hydatid cysts

underwent percutaneous treatment. All patients

were regularly k)llowed up every 3 months in their

Ustuns#{246}z et al.

92 AJR:172, January 1999

first year, every 6 months in their second year, and

then once a year subsequently until September1997. Sonography was used for follow-up. Fol-low-up criteria were the echo pattern and the size

and wall structure of the cyst. The follow-up pe-nod ranged from 7 to 67 months, with a mean of

37 months (SD, 18.7 months).Inclusion or exclusion criteria were determined

mainly in accordance with the sonographic type of

the cyst or cysts as described in the classificationof Gharbi et al. [ 13]. Patients with type I hydatid

cysts (pure fluid collection), type II hydatid cysts(fluid collection with a split wall), and type III hy-

datid cysts (fluid collection with daughter cyst)

with drainable matrices were included. Patients

with type III cysts containing nondrainable degen-crated matrices due to solid components, type IVcysts (heterogeneous echo pattern), or type V cysts

(reflecting calcified wall) were excluded. Patientswith ruptured (into the biliary tract, peritoneum, or

pleural cavity) or secondarily infected cysts and

patients who had not attended to follow-up sono-

graphic examinations were also excluded.

Fifty-six patients had one cyst (56 total), eight hadtwo cysts (16 total), four had three cysts (12 total),

one had four cysts (four total), two had five cysts (10total), and one had eight liver cysts (eight total) and

one kidney cyst, which was treated percutaneously

as well but excluded from the present liver study.Twenty-two patients had a history of hydatid

cyst or cysts treated surgically. One of these pa-

tients had three operations, 1 1 had two operations,

and one had one operation due to hydatid disease.One patient among these 22 had undergone sur-gery for both lung and liver hydatid cysts. The sur-

gery treated the pulmonary cyst successfully, but

the liver cyst recurred.The most common presenting symptom was

right upper quadrant pain (n = 27) or abdominal dis-comfort and swelling (n = 13). The other patientswere not symptomatic at the time of diagnosis. The

most common physical findings in patients who didnot undergo surgery were hepatomegaly (n = 34)

and liver masses with or without hepatomegaly (n =

12). The patients in whom disease recurred after sur-

gery experienced abdominal discomfort (n = 1 1) andpain (n = 6). The remaining five were asymptomatic.All recurrences were diagnosed with imaging,mainly sonography and Cl’.

After giving written informed consent, every

patient received prophylactic albendazole (Anda-

zol; Biofarma, 1st, Turkey), 15-20 mg/kg twice aday by mouth, starting 1 week before the proce-

dure and continuing for a total of 4 weeks.

An anesthesiology team was available to treatpossible hypersensitivity reactions during the in-

tervention. All interventions were carried out un-

der local anesthesia after peripheral IV accesswas obtained.

The technique of the procedure was chosenmainly according to the size of the cyst. Cystssmaller than 6 cm (n = 66) were treated with punc-ture, aspiration, injection, and reaspiration (PAIR),

a technique developed and described by Ben Amor

Ct al. [14]. Cysts larger than 6 cm (n = 40) were

treated with the catheterization technique de-

scribed by Akhan et al. [6]. A cyst 6 cm in diame-ter contains a volume of approximately I 00 cm3.Hence, catheterization is essential to ensure

quicker and more effective involution of the cay-ity; alcohol may further promote this involutionwith its sclerosing effect. Smaller cyst volumes,however, do not need catheterization or sclerother-

apy with alcohol. Besides, catheterization of such

small cysts requires more manipulation. whichmay mean an increased complication rate.

The PAIR technique may be summarized as

follows: puncture of the cyst with a 19-gaugesheathed needle under sonographic guidance, aspi-

ration of half the volume of the cyst, injection of

hypertonic saline solution (20%) amounting to onethird the initial estimated cyst volume, a 20-mm

wait, and reaspiration of the cyst fluid.

The catheterization technique differs from the

PAIR technique. After injection of the hypertonicsaline solution, a 6- to 9-French pigtail catheter is

placed into the cavity for 24 hr ofgravity drainage.

If cystographic study through the pigtail cathetershows no communication between the cyst cavity

and the biliary tract, a volume of absolute alcoholhalf the initially estimated volume of the cyst is

applied for 20 mm to produce protoscolecidal andsclerosing effects. If, however, cystographic study

through the pigtail catheter shows communication,

alcohol should not be used because secondarysclerosing cholangitis may result.

Because of high pressure inside hydatid cysts,

cyst fluid spreads out and contaminates the interven-

tion area at the time of the initial puncture. To avoid

this contamination, a one-way valve system was

adapted to the top of a 19-gauge sheathed needle,

and this type of needle was used in all patients.

All cyst fluid aspirated, both before and afterinjection of the hypertonic saline, was sent for cy-tologic and microbiologic examination. Staining

with neutral red indicated that the cyst was viable,and staining with methylene blue and eosin mdi-

cated that the cyst was not viable [15].

Results

Before the Procedure

All patients tolerated the oral albendazole

prophylaxis well for the first week, but seven

(9.7%) showed gastric intolerance after the

second week and had to stop taking the medi-

cation. No recurrence was seen in this group,

as opposed to the group treated for 4 weeks. In

three cysts from three patients, the endocyst

separated from the pericyst after 1 week of al-

bendazole therapy. These patients were given

albendazole therapy for an additional 7 weeks.

Because no additional sonographic change

was observed in this period, all three under-

went percutaneous therapy. Cyst contents aspi-

rated just before percutaneous treatment in

these three patients stained with neutral red, in-

dicating that the cysts were viable.

The average volume of cysts before the

procedure was 37 ml in the 66 treated by the

PAIR technique and 285 ml in the 40 treated

by the catheterization technique.

During the Procedure

Clear fluid under high pressure-occasion-

ally called “spring water”-was obtained at the

initial puncture, before the injection of saline

solution. This observation and the sonographi-

cally detected separation of the endocyst from

the pericyst were accepted as pathognomonic

for the viability of the hydatid cysts [6] (Fig. I).

The fluid became yellowish after injection of

the saline solution, and the endocyst separated

from the pericyst during the procedure in all pa-

tients. At the beginning of the reaspiration, no

fluid could be withdrawn in four of the 66 pa-

tients treated by the PAIR technique, mainly

because of needle occlusion by membrane

fragments. After simple maneuvers such as

changing the position of the needle, injecting

small amounts of saline solution, and pushing

back the membrane fragments by floppy J-type

guidewires, we were able to draw back the in-

jected fluid in two of these patients. The other

two patients, however, required catheterization

with a 10-French pigtail catheter.

No deaths or hypersensitivity reactions

occurred during the procedure.

After the Procedure

Eight patients (I I . I %) experienced minor

complications (fever and urticaria). Two pa-

tients (2.8%) presented with mild urticaria

within I .5-4 hr after the procedure and re-

sponded to antihistamines. Four patients

(5.6%) developed a mild fever spike that

subsided spontaneously without treatment.

Two patients (2.8%) presenting with both ur-

ticaria and fever were treated with antihista-

mines only.

Six patients (8.3%) experienced major

complications (cavitary infection and biliary

fistula). The residual cystic cavities became

infected in two patients (2.8%) treated by the

PAIR technique, 9 and I I days after the in-

terventions, and required percutaneous cath-

eter drainage for 5 and 7 days. Of four

patients (5.6%) who presented with biliary

fistulas, two required prolonged catheteriza-

tion, for 24 and 37 days. In one patient, the

fistula was managed by endoscopic papillot-

omy, irrigation, and nasobiliary drainage and

resolved within 39 days. The last patient of

these four also had endoscopic intervention,

but she eventually required surgery because

the fistula was still present (Fig. 2). The first

three fistula patients stayed in the hospital for

Fig. 1-21-year-old man with hepatomegaly.A, Sonogram obtained before intervention shows type I hydatid cyst of liver.B, Sonogram obtained 5 mm after injection of hypertonic saline solution reveals endocyst separated (arrows) from pericyst.Cand 0, Sonograms obtained at sixth (C) and 12th (D) months of follow-up show increasingly settling solid component.

Fig. 2.-53-year-old woman with percutaneously treatedhepatic hydatid cyst. Cystogram shows cystobiliaryfistula.

Percutaneous Treatment of Hydatid Cyst of the Liver


1 week before being discharged for outpa-

tient follow-up. The last patient was unable

to take care of herself at home. She stayed in

the hospital for 7 1 days.

Patients whose course was uncomplicated

stayed in the hospital only overnight and

were discharged after a routine sonographic

examination on the next day.

Follow-Up ofCyst Changes

The sonographic appearance generally

changed from cystic to solid. At the first fol-

low-up examination, the cysts generally were

more fluid than solid. Gradually. the solid

component of the cysts increased until. on

complete cure, only a solid cyst remnant was

seen (Fig. 3). Rarely, we could not detect

where the cyst had been (F’ = 4). The time re-

quired for a solid appearance to develop varied

according to the size of the original cyst and

the type oftreatment. Small cysts (6-s cm) be-

came solid in the catheterization group earlier

than in the PAIR group (average. 16 months).

The average time for a solid cyst remnant to

appear was 19 months (6 months to 3 years) in

the PAIR group and 26 months ( I I months to

4 years) in the catheterization group.

Cysts were considered to have recurred if

routine follow-up revealed them to be persis-

tently round and anechoic, with a regular and

thin wall and without a ruptured endocyst.

Although the cysts of two PAIR patients mi-tially showed a reduction in volume, 3- and

6-month follow-up examinations showed

that the cysts had recurred. Microscopic cx-

amination of aspirate from the cysts revealed

Ust#{252}ns#{246}zet al.


Fig. 3.-Temporal evolution of sono-graphic appearance of liver hydatidcyst during percutaneous treatmentA, Sonogram obtained before inter-vention shows type I hydatid cyst atright lobe of liver.B, Needle and hypertonic jet flow(arrow) are evident on sonogram ob-tamed during intervention.Cand 0, Sonograms obtained atfirst(C)and second (D)years offollow-up showsolid appearance of cyst remnant

neutral red staining, or viability. Both pa-

tients underwent a second, successful, PAIR

session and had no further recurrences.

The size and sonographic appearance of all

cysts changed after intervention. Immediately

after the procedure, a volume reduction of

78.0% occurred with the PAIR technique and

94.6% with the catheterization technique. Of

the cysts treated successfully without compli-

cation, the reduction in volume was 73.5%

with the PAIR technique and 87.0% with the

catheterization technique. These results were

obtained at the first follow-up sonographic ex-

amination in the third month.

Discussion

Hydatid disease is a major health problem in

endemic areas [1, 16]. Epidemiologic studies

indicate a pastoral distribution, with a concen-

tration in the sheep-raising and rural areas [16].

However, extensive immigration has spread hy-

datid disease worldwide; it is increasingly prey-

alent in areas, including Europe and North

America, previously known to be free from it [17].

This worldwide distribution requires that all

physicians be aware of hydatid disease.

The actual prevalence of hydatid disease is

unknown, mainly because of lack of reliable

screening methods. Gargouri et al. [18] found

that approximately 2% of the population in Tu-

nisia was infected, and they quoted this rate as

being “100 times higher than World Health Or-

ganization estimates.” Screening and diagnostic

studies ofhydatid disease have been improving,

and satisfactory diagnostic criteria have been

established with the help of new technology

such as sonography, CT, and MR imaging [19].

Among these, sonography is the accepted tech-

nique for general screening and follow-up and

is more reliable than serologic tests [19].

Percutaneous treatment of hydatid cysts has

been considered contraindicated because of

the risk of inducing anaphylactic shock, seed-

ing, and spillage [17]. This assumption is,

however, erroneous, having been brought into

question by many related studies of diagnos-

tic, experimental, and therapeutic percutane-

ous intervention series in which no additional

significant, immediate complications were ob-

served [12, 17, 18, 20-24]. Lewall and Mc-

Corkell [25] published their experiences with

20 cases of rupture of intrahepatic hydatid

cysts. No anaphylactic shock had then been

observed. The exact frequency of anaphylaxis

is not known. Obviously, the risk of anaphy-

laxis in percutaneous treatment is not signifi-

cantly different from that in surgical

intervention. No clear-cut criterion exists for

protection from anaphylaxis before interven-

tions [20]. Hence, anaphylaxis should always

be anticipated, and treatment should be readily

available for patients both in surgical and per-

cutaneous interventions.

Spillage of the cyst contents and dissemi-

nation into the peritoneal cavity has not, to

our knowledge, been reported in any short-

Percutaneous Treatment of Hydatid Cyst of the Liver


term study of percutaneously treated patients

[12, 17, 18, 20-241. The two long-term stud-

ies of percutaneously treated patients that we

are aware of [26, 271, and the present study,

have agreed with the results of short-term

studies. We believe the main reason for this

safety record was the use of a transhepatic

approach and real-time sonographic guid-

ance during needle insertion. The potential

for leakage of cyst contents into the hepatic

parenchyma before injection of the hyper-

tonic solution is only a theoretic risk, be-

cause it is almost eliminated in clinical

practice by the immature tract around the

needle and immediate cyst decompression.

The protective effect of albendazole reported

in one animal study is another factor against

potential spillage 1281 and the reason we

used prophylactic albendazole.

Because disseminated scoleces from a hy-

datid cyst can recur, regrowing and develop-

ing into mature cystic forms asexually, it is

imperative to follow up patients for a reason-

able period after the intervention. The time

of recurrence varies with the age of the pa-

tient and host factors and ranges from 6 to 36

months in one study 1291. That range is a

main reason that long-term studies are

needed. Unfortunately, detection of early re-

currence after treatment is still a problem be-

cause of the lack of a sensitive serologic test

for follow-up I 19J. The recurrence rate after

surgery varies widely. Postoperative recur-

rence rates less than I 2% were reported for

studies before 1980 129, 301, whereas recur-

rence rates of up to 30% have been reported

for studies after 1980 13, 31 J, in whichsonography and CT were readily used as the

follow-up tools. Befcre 1980, for example, a

surgical study group used laparoscopy for

evaluating recurrence in symptomatic cases

1291. In contrast, the recurrence rate in percu-

taneous series varies in a narrow range from

Fig.4.-43-year-old woman with eightliver cysts and one renal hydatid cystA, CT image obtained before percu-taneous treatment shows two he-patic cysts.B, CT image obtained 3 days aftersonographically guided percutaneoustreatment of same cysts showsmarked volume involution.

0% to 2% fl2, 17, 18, 21, 23, 24, 26, 271.

Sonography was the follow-up tool in these

reports. Persistence of round shape and

anechoic appearance, regularity and thin-

ness of the cyst wall, and absence of a rap-

tured endocyst during the routine follow-up

examinations were accepted as indicators of

recurrence. A change over time in the sono-

graphic appearance of the cavity after percu-

taneous treatment from cystic to solid. with a

final purely solid cyst remnant, is a widely

acknowledged sign of cure.

Two of our PAIR patients with type I hy-

datid cysts had recurrences 3 and 6 months

after the percutaneous treatment. These pen-

ods are too short for a real recurrence. As

mentioned befrre, the expected time for re-

currence varies between 6 and 36 months

[291. Suboptimal therapy may be considered

responsible for our recurrences. The possible

mechanism underlying this failure might be

the irregularities and undulation of the en-

docyst, creating pockets for live cyst con-

tents during the intervention and reducing

the time of contact between parasite and hy-

pertonic solution.

Surgical treatment for liver hydatid cysts

mainly involves evacuation of cyst contents, in-

jection of scolecidal agents into the cavity, re-

moval of the cyst contents, treatment of the

residual cavity with or without omentum, and

sometimes resection of the infested part of the

organ. The overall mortality and complication

rates of surgery depend on many factors includ-

ing the chosen surgical technique. the duration

of follow-up, and the presence of previous cyst-

related complications such as cholangitis or

rupture. The surgical mortality rate ranges be-

tween 0% and 6f�.3% [3-5, 32 I, and the surgi-

cal complication rate ranges between 12.5%

and 80.0% 3. 30. 32, 331. The mean hospital-

ization period after surgery is 14 days for un-

complicated cases and 30 days for complicated

cases [3-5. 281. The percutaneous treatment of

hydatid cysts in selected patients of our study

has better results. with no mortality, a 19.4%

complication rate, and a hospitalization time of

1 day in noncomplicated and I 7 days in com-

plicated cases. We did not include secondanly

infected or raptured cysts in this study.

Because repeated surgeries are technically

difficult because of adhesions and fibrosis,

recurrence of hydatid cysts after initial sun-

gery harbors additional morbidity besides

the well-known risk from general anesthesia.

For that reason. some patients of this study

were referred to our department because of

recurrences after surgery. No additional risk

has been reported for repeated sessions of

percutaneous treatment.

The number of hydatid cysts in a patient

may influence the length of the operation and

anesthesia. From this point of view, additional

hydatid cysts may mean additional complica-

tions. One patient in this study with eight liver

cysts and one renal hydatid cyst was treated

without any of the aforementioned risks (Fig.

4). Local anesthesia used in percutaneous

treatment is another advantage over the gen-

eral anesthesia used in surgical treatment.

The presence of jaundice with dilated bil-

iary ducts and a cystic lesion in the liver should

suggest the possibility of hydatid cyst rapture

into the biliary system [25 l� best revealed by a

sonographic examination. We did not include

these patients for percutaneous treatment be-

cause of the risk of secondary cholangitis

caused by chemical agents such as absolute al-

cohol or hypertonic saline solution 1341. We

had four patients who developed biliary fistu-

las after percutaneous treatment. All were

catheterization patients having hydatid cysts

larger than 10 cm. None of these patients had

obvious sonographic clues of a biliary commu-

nication before the treatment. The develop-

ment of these tistulas may be explained by

Ust#{252}ns#{246}zet al.


considering the changes in pressure gradients.

High intracystic pressure drops to normal dur-

ing or after the procedure. The previously non-

communicating biliary ducts surrounding the

cyst convert to a low resistance area where the

bile ducts may directly drain. This pressure

gradient affects a larger area, increasing the

chance of biliary communication in larger

cysts. On seeing these communications on

cystograms, we did not use absolute alcohol as

a sclerosing agent because of its potential

chemical effects, especially on the biliary tree.

The rest of the catheterization patients did not

show any bile duct communications in their

cystograms and thus underwent alcohol sclero-

therapy. We did not observe complications

such as sclerosing cholangitis on use of hyper-

tonic saline solution and absolute alcohol dur-

ing follow-up. Reinjection fluid was free of

bile in all PAIR patients, a finding that was ac-

cepted to indicate absence of communication.

Besides, during their follow-ups the PAIR pa-

tients displayed volumetric involution, which

means no extra input of bile into the cyst.

PAIR patients with secondary cavity in-

fection had cultures positive for Staphylo-

coccus aureus that were not related to the

biliary route of infection but instead to a pos-

sible external cutaneous or instrumental

source. These patients were treated with per-cutaneous drainage and antibiotics.

The fever seen just after the intervention

was accepted as a kind of reactive immune

response to the tissue degradation products

induced by the hypertonic saline solution,

ending with the release of pyrogenic media-tors. Generally, the fever disappeared in 12

hr without therapy.

The major complications were cavity infec-

tion, recurrence, and biliary rupture. Although

these were first reflected over the short term,

long-term results did not reveal any additional

complications such as cyst recurrences or scle-

rosing cholangitis and supported the favorable

short-term results of percutaneous treatment.

Although additional long-term and large-

scale studies are needed, this series provides

evidence that percutaneous hydatid cyst ther-

apy is an effective and safe procedure in prop-

erly selected patients. In conclusion, our

results indicate that percutaneous treatment of

hydatid disease is the best alternative among

the available techniques.

References

I. Matossion RM, Rickard MD, Smyth JD. Hydati-

dosis: a global problem of increasing importance.

WHO C/iron 1977;55:499-507

2. Kok AN, Yurtman T, Aydin NE. Sudden death due

to ruptured hydatid cyst of the liver. J Forensic

Sci 1993;38:978-980

3. Mentes A. Hydatid liver disease: a perspective in

treatment. Dig Dis 1994;l2:l50-l60

4. Bilge A, Sozuer EM. Diagnosis and surgical treat-

ment of hepatic hydatid disease. HPB Surg 1994;

8:77-81

5. Magistrelli P, Masetti R, Coppola R, et al. Surgi-

cal treatment of hydatid disease of the liver. Arch

Surg 1991;l26:5l8-523

6. Akhan 0, Dincer A, Gokoz A, et al. Percutaneous

treatment of abdominal hydatid cysts with hyper-

tonic saline and alcohol: an experimental study in

sheep. Invest Radio! 1993:28:121-1277. Akhan 0, Ozmen MN, DincerA, et al. Percutane-

ous treatment of pulmonary hydatid cysts. Car-

diovasc Intervent Radio! 1994:17:271-275

8. Morris DL. The use of albendazole in human hy-

datid disease. Ann Trnp Med Parasito! 1984;78:

204-205

9. Akkiz H, Akinoglu A, Colakoglu 5, et al. Endo-

scopic management of biliary hydatid disease.

Can J Surg 1996;39:287-292

10. Todorov 1, Vutova K, Mechkov 0, et al. Evalua-

tion of response to chemotherapy of human cystic

echinococcus. Br J Radio! 1990;63:523-531

11. Al Karawi M, Mohammed E, Yasawy I, et al. Non-

surgical endoscopic trans-papillary treatment of

ruptured echinococcus liver cyst obstructing the bil-

iary tree. Endoscopy 1987;l9:81-83

12. Mueller PR, Dawson SL, Ferrucci iT, Nardi GL.

Hepatic echinococcal cyst: successful percutane-

ous drainage. Radiology 1985;155:627-62813. Gharbi HA, Hassine W, Brauner MW, et al. Ultra-

sound examination of the hydatic liver. Radiology

1981; 139:459-46314. Ben Amor N, Gargoun M, Gharbi HA, et al. Treat-

ment du kyste du foie du mouton par ponction sous

echographie. Tunis Med 1986;64:325-33l15. Gori S. Campatelli A, Luchi 5, et al. Cytology in

the percutaneous treatment of hydatid cysts. Ada

C.vtol 1993;30:423-426

16. Kammerer WS, Schantz PM. Echinococcal dis-

ease. Infect Dis Clip, North Am 1993:7:605-616

17. Khuroo MS. Zargar SA, Mahajan R. Echinococ-

cus granulosus cysts in the liver: management

with percutaneous drainage. Radiology 1991 ; 180:

141-145

18. Gargouri M. Amor NB, Chehida FB, et al. Percu-

taneous treatment of hydatid cysts (echinococcus

granulosis). Cardiorasc Iniervent Radio! 1990:

13: 169-173

19. Suwan Z. Sonographic findings in hydatid disease

ofthe liver: comparison with other imaging meth-

ads. Ann Trop Med Parasito! 1995:89:261-269

20. McCorkell SJ. Unintended percutaneous aspira-

tion of pulmonary echinococcal cysts. AiR 1984;

143:123-126

21. Bret PM, Fond A, Bretagnolle M, et al. Percuta-

neous aspiration and drainage of hydatid cysts in

the liver. Radiology 1988;168:61 7-620

22. Filice C, Pirola F, Brunetti E, et al. A new thera-

peutic approach for hydatid liver cysts. Gastroen-

temlogv 1990:98:1366-1368

23. Acunas B, Rozanes I, Celik L, et al. Purely cystic

hydatid disease of the liver: treatment with percu-

taneous aspiration and injection of hypertonic sa-

line. Radiology 1992:182:541-543

24. Bastid C, Azar C, Doyer M. Percutaneous treat-

ment of hydatid cysts under sonographic guid-

ance. Dig Dis Sci 1994;39: I 576-I 580

25. Lewall DB, McCorkell SJ. Rupture of echinococ-

cal cysts: diagnosis, classification, and clinical

implications. AiR 1986; 146:39 1-394

26. Akhan 0. Ozmen MN, Dincer A, et al. Liver hy-

datid disease: long-term results of percutaneous

treatment. Radiology 1996:198:259-264

27. Filice C, Brunetti E. Use of PAIR in human cystic

echinococcus. Ada Tmp 1997:64:95-107

28. Moms DL, Chinnery JB, Hardcastle JD. Can al-

bendazole reduce the risk of implantation of

spilled protoscoleces? An animal study. Trans R

Soc Tmp Med Hvg 1986;80:48 1-484

29. Motaghian H. Saidi F. Postoperative recurrence

of hydatid disease. Br J Siug 1978:65:237-242

30. Barros JL. Hydatid disease of the liver. Am J Surg

1978;l35:597-600

31 . Little flsl, Hollands MT. Eckberg H. Recurrence of

hydatid disease. Wor!dJ Surg 1988:12:700-704

32. Aktan AO, Yalin R, Yegen C, Okboy N. Surgical

treatment of hepatic hydatid cysts. Acta Chir Be!g

1993;93: 15 1-153

33. Glevich IS, Ataev BA, Vafin AZ, et al. Relapses in

echinococcal disease [in Russian]. Vestn Khir Im I

I Grek 1980; 124:39-45

34. Pappalardo G, Frattaroli FM, loppolo A, et al.

Secondary sclerosing cholangitis: an experimen-

tal study. Eur Surg Res 1988;20:358-363

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PAIR for Hydatid